Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach selecting biologic therapy vs non-biologic DMARD (such as methotrexate) as initial therapy in patients with new RA diagnosis with significant erosive disease?
In my clinical experience, not everyone is the best candidate for methotrexate. Businessmen who feel alcohol consumption is part of their ability to finish business deals are uncomfortable taking methotrexate and I am uncomfortable prescribing for them. Men and women who are hoping to bear children ...
Is there utility in monitoring IgE levels in patients with IgG4-RD?
Serum IgE levels are associated with disease extent/severity and risk of relapse in patients with IgG4-RD. In some patients (although this is not true for all patients), IgE decreases following treatment and increases with disease flares. However, some patients who have extreme IgE elevations at bas...
How do you gain access to quinacrine, and what has your recent experience been?
It can be gotten from a few compounding pharmacies. The cost is high (around $400 a month) and usually not covered by insurance. One compounding pharmacy that often carries it is ChemistryRx in Philadelphia.
How would you approach a patient with axial spondyloarthritis who develops new-onset proteinuria?
I would approach the workup for proteinuria based on the differential diagnosis with leading etiologies including, acute illness, diabetes, nephrotic syndrome (minimal change disease, FSGS, membranous neuropathy), drug-induced proteinuria, vasculitis, and of course IgA neuropathy. Standard studies i...
What would be your approach to a SLE patient who is triple APS positive, has no prior VTE/obstetric events, is stable on HCQ and low dose aspirin, and wants to become pregnant?
As long as lupus is well controlled, I would not recommend making any changes. I would also reassure this patient that having prior successful pregnancies (based on the information provided in the question stating that there were no prior obstetric complications) is a good sign. I would not prescrib...
Is it ever appropriate to restart bipshosphonates following a drug holiday in a patient with a prior atypical hip fracture?
I agree with Dr. @Dr. First Last. I am not likely to ever prescribe a bisphosphonate after someone has had an AFF (or ONJ) attributed to the bisphosphonate. Anabolics make sense if you can get them paid for. Raloxifene is fine but there is no evidence for non-vertebral fracture risk reduction. Venou...
How do you treat Raynaud's in patients with baseline low blood pressure?
These can be very challenging patients. I tend to try 2.5 mg amlodipine at night which they can often tolerate. If there is a component of anxiety or stress/emotion to the Raynaud's, particularly in primary Raynaud's, fluoxetine can be useful. Some patients can tolerate half-dose sildenafil (10mg TI...
Does the presence of facet joint effusions on lumbar spine MRI increase your suspicion for axial spondyloarthritis?
Isolated joint effusions in the lumbar spine are not indicators of AxSpA. Involvement in the spine in AxSpA involves more than the facet joint including adjacent entheses linking one vertebra to another and the costochondral joints. To arrive at this answer, I spoke to rheumatologists with expertise...
Are there concerns with using sulfasalazine in SLE?
A very practical question:1. Yes, there is a concern theoretically; but you can use SSZ in lupus patients in certain circumstances.Sulfonamides are divided up into antibiotic (abx) sulfonamides (like trimethoprim-sulfamethoxazole, TMP-SMX) and non-abx sulfonamides (e.g. furosemide, hydrochlorothiazi...
How often do you monitor labs in patients taking methotrexate?
Lab monitoring for patients taking MTX should be based on a few key principles. It should be done at least on a quarterly basis, ie every 3 months, if the patient is prescribed a stable dose and does not belong to one of the higher risk categories for the development of toxicities. These risk factor...